Coarctation of aorta

Vignette says a 35 year old female presents to the cardiology clinic with chief complaints of high blood pressure for the last 5 years for which she takes 3 different types of antihypertensive medications; She also complains of persistent headaches, dizziness, and shortness of breath on exertion over the past years; There is no history of cardiovascular disease in the family; Vital signs show blood pressure of 180/100 mm of Hg in right arm and 130/80 mm of Hg in left arm, pulse rate of 88 beats/min, oxygen saturation is 94% in RA and temperature is 97.4 F; On examination radial pulse is strong and fast whereas femoral pulse is weak and delayed (i.e. radio femoral delay); ECG shows left ventricular hypertrophy; Chest X ray shows bilateral rib notching and focal indentation of the distal aortic arch; Echocardiography shows LVH; Routine laboratory reports are within normal limit; USG (A+P) shows normal scan; Diagnosis?

Diagnosis is coarctation of the aorta. 

Coarctation of aorta is the narrowing of the aorta just distal to the left subclavian likely near the insertion/opening of the ductus arteriosus (i.e. "juxta ductal"); Majority of coarctations are diagnosed during childhood, however some cases remain asymptomatic until adulthood. 

Presents with secondary hypertension, radio femoral delay, disproportionate blood pressure between upper and lower extremities (i.e. BP in upper extremity > lower extremity) and left ventricular hypertrophy. Associated with bicuspid aortic valves.

Diagnosis:- 

1. Chest x ray shows rib notching and '"figure 3 sign". 

2. ECG shows LVH. 

3. Echocardiography shows narrowing of the aorta near the ligamentum arteriosum and LVH. 

4. CT Angiography/Cardiac MRI shows the presence, site and severity of coarctation as well as collateral vessels. 

Management:- 

1. Surgical repair involves excision of the narrowed segment and direct anastomosis of the normal aorta whereas transcatheter repair involves balloon dilation with stent placement.